Industrial Process Safety Lessons from major accidents and their application in traditional workplace safety and health

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Industrial Process Safety Lessons from major
accidents and their application in traditional
workplace safety and health
Graham D. Creedy, P. Eng, FCIC, FEIC Formerly
Senior Manager, Responsible Care Canadian
Chemical Producers Association (now Chemistry
Industry Association of Canada) gcreedy_at_canadianch
emistry.ca System Safety Society Spring
Event May 26, 2011
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Overview

• How I got into this
• The evolution of the philosophy of industrial
  safety and prevention of major accidents
• Some key insights and concepts
• How these apply to management of workplace safety
  in various sectors and at different levels of the
  organization

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Some history

• 1984 Bhopal accident is wake-up call to chemical
  industry
• Industry responsibility to understand and control
  hazards and risks
• Responsible Care launched in Canada
• Principles, codes, commitment, tools, support,
  progress tracking, verification
• Major Industrial Accidents Council of Canada
  1987-1999

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Safety Performance by Industry Sector Injuries
illnesses per 200,000 hours worked (2002)
Source US Bureau of Labor Statistics
(www.bls.gov/iif)
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Relative risks of fatal accidents in the work
place of selected occupations
Fishers (as an occupation) 35.1
Timber cutters (as an occupation) 29.7
Airplane pilots (as an occupation) 14.9
Garbage collectors 12.9
Roofers 8.4
Taxi drivers 8.2
Farm occupations 6.5
Protective services (fire fighters, police guards, etc.) 2.7
Average job 1.0
Grocery store employees 0.91
Chemical and allied products 0.81
Finance, insurance and real estate 0.23
Sanders, R.E, J. Hazardous Materials 115 (2004)
p143, citing Toscano (1997)
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Chemistry Industry Association of Canada Member
Performance
CIAC website www.canadianchemistry.ca Staff
contact Stephanie Butler 613-237-6215 x 245
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A proactive approach focuses on these
categories, but be careful you may miss the
really serious ones!
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Terminology

• Process hazard
• A physical situation with potential to cause harm
  to people, property or the environment
• Risk (acute)
• probability x consequences of an undesired event
  occurring

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They thought they were safe

• Good companies can be lulled into a false sense
  of security by their performance in personal
  safety and health
• They may not realise how vulnerable they are to a
  major accident until it happens
• Subsequent investigations typically show that
  there were multiple causes, and many of these
  were known long before the event

BP Deepwater Horizon
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Why and how defences fail

• People often assume systems work as intended,
  despite warning signs
• Examples of good performance are cited as
  representing the whole, while poor ones are
  overlooked or soon forgotten
• Analysis of failure modes and effects should
  include human and organizational aspects as well
  as equipment, physical and IT systems

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• Process safety management
• Recognition of seriousness of consequences and
  mechanisms of causation lead to focus on the
  process rather than the individual worker
• Many of the key decisions influencing safety may
  be beyond the control of the worker or even the
  site they may be made by people at another
  site, country or organization
• Causes differ from those for personnel safety
• Need to look at the whole materials, equipment
  and systems and consider individuals and
  procedures as part of the system
• Management system approach for control

Flixborough, Bhopal, Pasadena
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Scope (elements of process safety management)

1. Accountability
2. Process Knowledge and Documentation
3. Capital Project Review and Design Procedures
4. Process Risk Management
5. Management of Change
6. Process and Equipment Integrity
7. Human Factors
8. Training and Performance
9. Incident Investigation
10. Company Standards, Codes and Regulations
11. Audits and Corrective Actions
12. Enhancement of Process Safety Knowledge

CCPS Guidelines for Technical Management of
Chemical Process Safety
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Functions of a management system
Planning Organizing
Leadership
Controlling Implementing
Direction
Measurement
Structure
Results
CCPS Guidelines for Technical Management of
Chemical Process Safety
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Features and characteristics of a management
system for process safety
Planning Explicit goals and objectives Well-defined scope Clear-cut desired outputs Consideration of alternative achievement mechanisms Well-defined inputs and resource requirements Identification of needed tools and training Organizing Strong sponsorship Clear lines of authority Explicit assignments of roles and responsibilities Formal procedures Internal coordination and communication
Implementing Detailed work plans Specific milestones for accomplishments Initiating mechanisms Controlling Performance standards and measurement methods Checks and balances Performance measurement and reporting Internal reviews Variance procedures Audit mechanisms Corrective action mechanisms Procedure renewal and reauthorization
CCPS Guidelines for Technical Management of
Chemical Process Safety
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Examples of PSM management systems concerns at
different organizational levels
CCPS Guidelines for Technical Management of
Chemical Process Safety
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A page from the Site Self-Assessment Tool
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Use of self-assessment tool for collective
progress reporting and actionAs of August 29,
2008 compared with past five years (some site
changes)Target for meeting Essential level
June 30, 2003
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Process-Related Incident Measure (PRIM) 2007
Findings All Elements
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Assessing an organizations safety effectiveness

• What is the safety policy and culture (written,
  unwritten)?
• How are the following handled?
• Establishing what has to be done
• Benchmarking
• Communicating
• Assigning accountabilities
• Ensuring that it gets done
• Monitoring and corrective action
• Evidence (documentation) and audit process
• Resourcing not only for ideal but for
  anticipated conditions
• Balancing with other priorities
• How are exceptions handled?

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Consider targets in groups

• Those who
• Dont care
• Dont know (and perhaps dont know that they
  dont know)
• Did know, but may have forgotten or could have
  gaps in application (and perhaps dont realize
  it)

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• Excellent guidance exists but how is it being
  used?

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The New Product Introduction Curve

• Can be applied to adoption of new ideas
• Categories differ by ability and more
  importantly, motivation

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Accountability

• Management commitment at all levels
• Status of process safety compared to other
  organizational objectives such as output, quality
  and cost
• Objectives must be supported by appropriate
  resources
• Be accessible for guidance, communicate and lead

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Management of Change

• Change of process technology
• Change of facility
• Organizational changes
• Variance procedures
• Permanent changes
• Temporary changes

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Process and Equipment Integrity

• Design to handle all anticipated conditions, not
  just ideal or typical ones
• Make sure what you get is what you designed
  (construction, installation)
• Test to make sure the design is indeed valid
• Make sure it stays that way
• Preventative maintenance
• Ongoing maintenance
• Review
• Be especially careful of automatic safeguards

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• Consider operator as fallible human performing
  tasks in background
• Design for error tolerance, not just prevention
• detection
• correction

Buncefield, UK
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• Realization of significance of sociocultural
  factors in human thought processes and hence in
  behaviours

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Human behaviour aspects
Familiarity to engineers More

• People, and most organizations, dont intend to
  get hurt (have accidents)
• To understand why they do leads us eventually
  into understanding human behaviour, both at the
  individual and organizational level, and
  involves
• Physical interface
• Ergonomics
• Psychological interface
• Perception, decision-making, control actions
• Human thought processes
• Basis for reaching decisions
• Ideal versus actual behaviour
• Social psychology
• Relationships with others
• Organizational behaviour

Less
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Human behaviour modes

• Instead of looking at the ways in which people
  can fail, look at how they function normally
• Skill-based
• Rapid responses to internal states with only
  occasional attention to external info to check
  that events are going according to plan
• Often starts out as rule-based
• Rule-based
• IF, THEN
• Rules need not make sense they only need to
  work, and one has to know the conditions under
  which a particular rule applies
• Knowledge-based
• Used when no rules apply but some appropriate
  action must be found
• Slowest, but most flexible

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Reasons Cheese Model James Reason,
presentation to Eurocontrol 2004
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Active and latent failures

• Active
• Immediately adverse effect
• Similar to unsafe act
• Latent
• Effect may not be noticeable for some time, if at
  all
• Similar to resident pathogen. Unforeseen
  trigger conditions could activate the pathogens
  and defences could be undermined or unexpectedly
  outflanked

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A Classic Example of a Latent Failure

• Hazard of material known, but lack of awareness
  of potential system failure mode leads to
  defective procedure design through management
  decision

Epichlorhydrin fire, Avonmouth, UK
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And another
Danvers, MA, Nov 2006 Solvent explosion at
printing ink factory

• Hazards known, but defences compromised by
  apparently benign change
• Latent error in procedure design creates
  vulnerability to likely execution error

US Chemical Safety Board
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And another

• Hazard of material not obvious (despite history)
• Latent error allowed dust to accumulate, creating
  conditions for subsequent events

Scottsbluff, NE 1996
Port Wentworth, GA 2007
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Lessons from other fields

• Aerospace and nuclear show how significant human
  and organizational aspects can be even where the
  obvious signs of failure are technical in nature
• Finance shows
• Relevance of such factors without technical
  distractions
• How fast a system can deteriorate once controls
  are relaxed
• How wrong risk assessments can influence bad
  policy decisions

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Relevance of organizational factors

• The relevance of organizational factors has
  also been graphically and tragically revealed in
  the inquiry reports of recent UK transportation
  and offshore oil disasters.
• Prior to ..., senior managers in all the
  organizations propounded the pre-eminence of
  safety. They believed in the efficacy of the
  regulatory system, in the adequacy of their
  existing programs, and in their confidence of the
  skills and motivation of their staff.
• The inquiry reports reveal that their belief in
  safety was a mirage, their systems inadequate,
  and operator errors and violations commonplace.
• The inquiry reports stated that ultimate
  responsibility lay with complacent directors and
  managers who had failed to ensure that their good
  intentions were translated into a practical and
  monitored reality. Moreover, the weaknesses so
  starkly revealed were not matters of substantial
  concern to the regulatory authorities before the
  accidents.

HSC, 1993
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Factors that can influence likelihood of failure

• Organizational culture
• the way we do things around here when no-one
  is looking
• increasingly being recognized as one of the most
  important factors in major accidents
• perceived balance between output, cost and safety
  is heavily dependent on this culture, and
  influences whether personnel work in a certain
  way because they believe the company and their
  co-workers feel it is the right way to do things,
  or whether they are simply going through the
  motions.

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In general, safety gets better as society learns
more
Standard of Safety
Time
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But the rate of improvement is not steady
Standard of Safety
x 10
Time
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In fact, the curve can be one of periodic rapid
gains followed by gradual but increasing declines
Note how the rate of decay can be expected to
increase due to normalization of deviance
Standard of Safety
x 100
Time
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Organizational Culture Model James W. Bayer,
Senior VP Mfg, Lyondell Chemical Company
Strong
Tribal
Operational Excellence
People
Chaotic
Bureaucratic
Weak
Strong
Systems
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Preservation or loss of corporate memory

• Demographic effects
• Less staff
• Experienced cohort leaving or left
• Skills transfer senior gt (middle) gt junior
• Replacements understand the way something is
  done, but not why it is done that way, the
  potential consequences of doing it differently
  and how to detect and recover from undesired
  actions
• We are starting to see lowered standards of
  design and supervision that fifteen years ago
  would have been unthinkable in the chemical
  industry (Challenger, 2004)

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• What does an organizations investigation of its
  failures reveal about its
• Culture
• Management system?

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• Knowledge
• Never realized problem could occur (benchmarking
  error)
• was it treated as a unique deficiency?
• was there a broader review of the benchmarking
  process to find if there are other areas where
  knowledge could be deficient?
• Policy
• Thought situation would be acceptable but didnt
  realize full implications until it happened
• Does it appear to be acceptable now?
• Was review of policy and accountability limited
  or broad in scope?
• System design
• Even if everything had been done as intended,
  problem would still have occurred
• How comprehensive was analysis of system
  deficiencies and practicality of solutions?
• How effective is action plan and follow through?
• Was review of system design limited or broad in
  scope?
• System execution (management system error)
• Problem occurred because someone or something did
  not perform as intended
• Did analysis consider why execution not as
  intended?
• Was corrective action appropriate and balanced?
• Was review of system execution limited or broad
  in scope?

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Dealing with a Safety (or Engineering) Problem

• Finding out who youre dealing with
• Where is the organization on the curve?
  (generally, and re the specific issue or problem)
• Where are the people youre dealing with on the
  curve? (generally, and re the issue or problem)
• Finding out what to do
• Benchmark dont try to reinvent the wheel
  unless youre sure there isnt one already (or
  youve time and its fun to do so)
• Find out what others are doing about it
• Read the instructions
• Identify/define the issue
• If its likely to be regulated, check with
  government agencies, trade associations, web,
  internet
• If not regulated but likely good industry
  practice, check suppliers, other users of same
  material or item, other users of similar items,
  other industry contacts but test the info!!!
  (cross-check, ask if it makes sense)
• Check standard reference works, (Lees, CCPS, etc)
• Doing it
• Try to think of all situations that are likely to
  occur (process, eqpt, people)
• KISS, keep it user-friendly, show basis for
  decisions if practical to do so
• Follow up afterwards to see how its working

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Questions?